New Patient Safety Video Now Available

The OPTN Operations and Safety Committee continues to promote a “culture of safety” to educate members about prevention and effective practices. The Committee’s Patient Safety Advisory Group worked with UNOS to develop the latest video in its patient safety series. You can find all of these webinars on UNOS Connect, UNOS’ learning management system. From the Course Catalog, select Patient Safety and choose the video you wish to view. To register and begin the process, click the Entrance Survey button.

Latest video

Infectious Disease Verification in the Living Donor

Three living donor events have occurred where either a near miss or accidental disease transmission of hepatitis C took place despite donor test results being available to indicate infection. These incidents stemmed from human error and lack of standard processes to review test results and confirm the appropriateness of those results prior to living donor organ recovery. In this video, the Operations and Safety Committee highlights patient safety practices that can help to prevent such errors by developing a standard operating procedure for verification of infectious disease test results prior to living donor recovery.

Intended Audience

Living Donor Recovery Hospitals

OPOs

Transplant Hospitals

Objectives

Discuss the benefits of having a standard operating procedure for verification of living donor infectious disease test results.

Illustrate elements in a standard operating procedure that ensure living donor infectious disease test results are reviewed and acted upon prior to organ recovery.

Once you pass the assessment and complete the exit survey, your certificate will be available on your transcript.

You must pass the assessment in order to receive a certificate. You must receive a passing score of 80% to receive a “pass” status on UNOS Connect. After three completion attempts, you will be required to re-register for the entire course. Don’t forget to complete the exit survey in UNOS Connect. In order to view your certificate in your transcript, you must complete the survey.

May 2016: This video focuses on ABO verification in the OR. Correct determination, reporting, and verification of donor and recipient blood types are key components of the safety system built within OPTN policy and UNet to ensure the correct organ will be transplanted into the correct recipient. Failure in any part of the system can have grave consequences including graft failure or even patient death. Since 2000, we’ve identified six cases of unintentional ABO incompatible transplants. OPTN policy changes related to ABO verification will take effect on June 23, 2016. Watch this video to learn how your program can prepare for the upcoming policy changes related to organ check in and pre-transplant verification.

January 2016: This video focuses on how ineffective communication led to hemodilution calculation errors. Hemodiluted blood specimens can produce false-negative results in donor testing, thus the accurate assessment for minimizing the risk of infectious disease transmission through organ transplantation is vital to patient safety.

October 2015: This video focuses on how ineffective communication led to the discard of a liver. Based on the most current data, communication issues are the most frequently reported safety events.

May 2015: The committee released a video containing two scenarios that illustrated the downstream consequences of ineffective communication and their impact on patient safety. You can also view a transcript of that video and a reference list.